Assessment of patient follow-up from student-run free eye clinic to county ophthalmology clinic.

The Ophthalmology Student Interest Group at Indiana University School of Medicine provides a free student-run eye screening clinic for an underserved community in Indianapolis. Patients with abnormal findings are referred to the ophthalmology service of the local county hospital for further evaluation. This retrospective chart review studied 180 patients referred from our free eye clinic to follow up at the ophthalmology service of a local county hospital from October 2013 to February 2020. This study investigated factors impacting follow-up of patients by analyzing demographics, medical history, insurance coverage, and final diagnoses at follow-up. Thirty-five (19.4%) of 180 patients successfully followed up at the local county hospital with an average time to follow-up of 14.4 (± 15.9) months. Mean patient age was 51 (± 13.6) with nearly equal numbers of males and females. The most common diagnoses at follow-up included refractive error (51.4%), cataract (45.7%), and glaucoma (28.6%). Patients with diabetes diagnoses or Healthy Indiana Plan insurance coverage had increased probability of follow-up. This study reveals gaps in timely follow-up to the local county hospital, demonstrating the current limitations of our free clinic in connecting patients to more definitive care and the need for an improved referral process.

Preventable Readmissions Following Common Cancer Surgeries: Lessons Learned from New York State and Targets for Improvement.

BACKGROUND: Potentially preventable readmissions of surgical oncology patients offer opportunities to improve quality of care. Identifying and subsequently addressing remediable causes of readmissions may improve patient-centered care. OBJECTIVES: To identify factors associated with potentially preventable readmissions after index cancer operation. METHODS: The New York State hospital discharge database was used to identify patients undergoing common cancer operations via principal diagnosis and procedure codes between the years 2010 and 2014. The 30-day readmissions were identified and risk factors for potentially preventable readmissions were analyzed using competing risk analysis. RESULTS: A total of 53,740 cancer surgeries performed for the following tumor types were analyzed: colorectal (CRC) (42%), kidney (22%), liver (2%), lung (25%), ovary (4%), pancreas (4%), and uterine (1%). The 30-day readmission rate was 11.97%, 47% of which were identified as potentially preventable. The most common cause of potentially preventable readmissions was sepsis (48%). Pancreatic cancer had the highest overall readmission rate (22%) and CRC had the highest percentage of potentially preventable readmissions (51%, hazard ratio [HR] 1.42, 95% confidence interval [95%CI] 1.28-1.61). Risk factors associated with preventable readmissions included discharge disposition to a skilled nursing facility (HR 2.22, 95%CI 1.99-2.48) and the need for home healthcare (HR 1.61, 95%CI 1.48-1.75). CONCLUSIONS: Almost half of the 30-day readmissions were potentially preventable and attributed to high rates of sepsis, surgical site infections, dehydration, and electrolyte disorders. These results can be further validated for identifying broad targets for improvement.

Telemedicine in surgery during COVID-19 pandemic: are we doing enough?

INTRODUCTION: The aim of this systematic review was to report and to analyze if there is and what is the impact of telemedicine in the surgical practice during COVID-19 pandemic. Many authors have posited that the pandemic urged a high implementation of the telemedicine service even in surgical specialties, however, the impact of this change of the clinical practice has been variably reported and its utilization in general surgery is uncertain. EVIDENCE ACQUISITION: All articles from any country written in English, Italian, Spanish, or French, about the use of telemedicine for indication to surgical treatment or for 30-day postoperative follow-up in general surgery during the COVID 19 outbreak, from the March 1, 2020, to December 1, 2020, were included. EVIDENCE SYNTHESIS: Two hundred nine articles were fully analyzed, and 207 further articles were excluded. Finally, 2 articles, both published in October 2020, were included in the present systematic review. CONCLUSIONS: In conclusion, the rapid spread of SARS-CoV-2 pandemic has forced to review the traditional methods to deliver surgical assistance and urged surgeons to find alternative methods to continue their practice. The literature about this topic is yet scarce and many questions regarding its efficacy in improving patients' health, cost-effectiveness and user satisfaction remain unsolved.

The impact of operative approach on postoperative outcomes and healthcare utilization after colectomy.

BACKGROUND: To evaluate national trends in adoption of different surgical approaches for colectomy and compare clinical outcomes and resource utilization between approaches. METHODS: Retrospective study of patients aged ≥18 years who underwent elective inpatient left or right colectomy between 2010 and 2019 from the Premier Healthcare Database. Patients were classified by operative approach: open, minimally invasive: either laparoscopic or robotic. Postoperative outcomes assessed within index hospitalization include operating room time, hospital length of stay, rates of conversion to open surgery, reoperation, and complications. Post-discharge readmission, hospital-based encounters, and costs were collected to 30 days post-discharge. Multivariable regression models were used to compare outcomes between operative approaches adjusted for patient baseline characteristics and clustering within hospitals. RESULTS: Among 206,967 patients, the robotic approach rates increased from 2.1%/1.6% (2010) to 32.6%/26.8% (2019) for left/right colectomy, offset by a decrease in both open and laparoscopic approaches. Median length of stay for both left and right colectomies was significantly longer in open (6 days) and laparoscopic (5 days) compared to robotic surgery (4 days; all P values <.001). Robotic surgery compared to open and laparoscopic was associated with a significantly lower conversion rate, development of ileus, overall complications, and 30-day hospital encounters. Robotic surgery further demonstrated lower mortality, reoperations, postoperative bleeding, and readmission rates for left and right colectomies than open. Robotic surgery had significantly longer operating room times and higher costs than either open or laparoscopic. CONCLUSIONS: Robotic surgery is increasingly being used in colon surgery, with outcomes equivalent and in some domains superior to laparoscopic.

Perfil de prematuros em atendimento fonoaudiológico em um ambulatório de follow up / Profile of premature infants undergoing speech-language-hearing care at a follow-up outpatient center

RESUMO Objetivo descrever o perfil de crianças pré-termo, segundo aspectos sociodemográficos, clínicos e assistenciais, e a associação com dados perinatais e pós-natais. Métodos estudo observacional descritivo transversal, aprovado pelo Comitê de Ética em Pesquisa da Universidade Federal de Minas Gerais - CEP-UFMG, sob o Parecer 3.615.440, realizado por meio da análise de 749 prontuários de crianças pré-termo, atendidas no setor de Fonoaudiologia de ambulatório multidisciplinar de follow-up. Foram incluídos no estudo todos os prontuários do período de 2009 a 2019. Para as análises de associação foram utilizados os testes Qui-quadrado de Pearson e Kruskal-Wallis, sendo considerados como valores com significância estatística os que apresentaram valor de p≤0,05. Resultados verificou-se distribuição similar entre os sexos feminino e masculino e a maior parte das crianças com prematuridade moderada a tardia. A maioria dos pais apresentou ensino médio completo, com renda familiar de até dois salários mínimos (60,0%). Quanto aos aspectos clínicos, observou-se significância estatística (p≤0,001) na associação da idade gestacional com as seguintes variáveis: peso ao nascimento, estatura, perímetro cefálico, uso do Método Canguru, alimentação na alta, drogas ototóxicas, hemorragia intracraniana, sepse e icterícia. A maioria dos bebês (99,9%) realizou o Teste Guthrie com resultado adequado (95,3%). Da mesma forma, referente à realização da Triagem Auditiva Neonatal - (79,9%), com resultado adequado (89,4%). Conclusão a maioria das famílias era de baixa renda, com bebês apresentando prematuridade tardia. Observou-se significância estatística para as variáveis: tipo de parto, peso, estatura, perímetro cefálico, uso de drogas ototóxicas, hemorragia intracraniana, sepse e icterícia, com alterações predominantes em prematuros extremos.

ABSTRACT Purpose to describe the profile of preterm children based on sociodemographic, clinical, and assistance aspects, and their association with peri- and postnatal data. Methods observational, descriptive, cross-sectional study, approved by the Research Ethics Committee of the Universidade Federal de Minas Gerais (UFMG, Brazil), under evaluation report no. 3,615.440. It was based on the analysis of 749 medical records of preterm children attended at the speech-language-hearing department of a multidisciplinary follow-up outpatient center. All medical records from 2009 to 2019 were included in the study. The association analyses were made with the Pearson chi-square and Kruskal-Wallis tests, and the statistically significant values were set at p≤0.05. Results the sample was evenly distributed between females and males, and most of them were moderate-to-late premature children. Most parents had graduated from high school, earning up to two minimum wages (60.0%). As for the clinical aspects, there was a statistically significant association (p≤0.001) between gestational age and birth weight, length, head circumference, use of kangaroo care, feeding method at discharge, ototoxic drugs, intracranial hemorrhage, sepsis, and jaundice. Most babies (99.9%) were submitted to the Guthrie test, with normal results (95.3%). It was likewise with the Neonatal Hearing Screening (79.9%), with normal results (89.4%). Conclusion most of the sample were from low-income families, with late premature babies. There was a statistical significance for type of delivery, weight, length, head circumference, ototoxic drug use, intracranial hemorrhage, sepsis, and jaundice, with changes occurring predominantly in extremely premature infants.

Achieving integrated self-directed Cancer aftercare (ASICA) for melanoma: how a digital intervention to support total skin self-examination was used by people treated for cutaneous melanoma.

BACKGROUND: Melanoma incidence has quadrupled since 1970 and melanoma is now the second most common cancer in individuals under 50. Targeted immunotherapies for melanoma now potentially enable long-term remission even in advanced melanoma, but these melanoma survivors require ongoing surveillance, with implications for NHS resources and significant social and psychological consequences for patients. Total skin self-examination (TSSE) can detect recurrence earlier and improve clinical outcomes but is underperformed in the UK. To support survivors, the Achieving Self-directed Integrated Cancer Aftercare (ASICA) intervention was developed to prompt and improve TSSE performance, with subsequent reporting of concerns and submission of skin photos to a Dermatology Nurse Practitioner (DNP). ASICA was delivered as a randomized pilot trial. METHODS: This paper reports on process evaluation. Data on participants' demographics and the concerns they reported during the trial were tabulated and displayed using Microsoft Excel and SPSS. We explored which participants used ASICA, and how frequently, to report any skin concerns. We also determined how the interactions had worked in terms of quality of skin photographs submitted, clinical assessments made by the DNP, and the assessments and decisions made for each concern. Finally, we explored significant events occurring during the trial. Data on participants' demographics and the concerns they reported during the trial were tabulated and displayed using SPSS. A semi-structured interview was undertaken with the DNP to gain perspective on the range of concerns presented and how they were resolved. RESULTS: Of 121 recruited melanoma patients receiving ASICA for 12 months, 69 participants submitted a total of 123 reports detailing 189 separate skin-related concerns and including 188 skin photographs. Where participants fully complied with follow-up by the DNP, concerns were usually resolved remotely, but 19 (10.1%) were seen at a secondary care clinic and 14 (7.4%) referred to their GP. 49 (25.9%) of concerns were not completely resolved due to partial non-compliance with DNP follow-up. CONCLUSION: Melanoma patients randomized to the ASICA intervention were able to report skin-related concerns that could be resolved remotely through interaction with a DNP. Feasibility issues highlighted by ASICA will support further development and optimization of this digital tool. TRIAL REGISTRATION: Clinical Trials.gov , NCT03328247 . Registered on 1 November 2017.

Timing and Cost of Wound Complications After Colorectal Resection.

BACKGROUND: More than 50% of postoperative wound complications occur after discharge. They are the most common postoperative complication and the most common reason for readmission after a surgical procedure. Little is known about the long-term costs of postdischarge wound complications after surgery. OBJECTIVE: We sought to understand the differences in costs and characteristics of wound complications identified after hospital discharge for patients undergoing colorectal surgery in comparison with in-hospital complications. DESIGN: This is an observational cohort study using Veterans Health Administration Surgical Quality Improvement Program data. SETTING: This study was conducted at a Veterans Affairs medical center. SETTING: Patients undergoing colorectal resection between October 1, 2007 and September 30, 2014. MAIN OUTCOME MEASURES: The primary outcomes measured were adjusted costs of care at discharge, 30 days, and 90 days after surgery. RESULTS: Of 20,146 procedures, 11.9% had a wound complication within 30 days of surgery (49.2% index-hospital, 50.8% postdischarge). In comparison with patients with index-hospital complications, patients with postdischarge complications had fewer superficial infections (65.0% vs 72.2%, p < 0.01), more organ/space surgical site infections (14.3% vs 10.1%, p < 0.01), and higher rates of diabetes (29.1% vs 25.0%, p = 0.02), and they were to have had a laparoscopic approach for their surgery (24.7% vs 18.2%, p < 0.01). The average cost including surgery at 30 days was $37,315 (SD = $29,319). Compared with index-hospital wound complications, postdischarge wound complications were $9500 (22%, p < 0.001) less expensive at 30 days and $9736 (15%, p < 0.001) less expensive at 90 days. Patients with an index-hospital wound complication were 40% less likely to require readmission at 30 days, but their readmissions were $12,518 more expensive than readmissions among patients with a newly identified postdischarge wound complication (p < 0.001). LIMITATIONS: This study was limited to patient characteristics and costs accrued only within the Veterans Affairs system. CONCLUSIONS: Patients with postdischarge wound complications have lower 30- and 90-day postoperative costs than those with wound complications identified during their index hospitalization and almost half were managed as an outpatient. TIEMPO Y COSTO DE LAS COMPLICACIONES LA HERIDA DESPUS DE LA RESECCIN COLORRECTAL: ANTECEDENTES:Más del 50% de complicaciones postoperatorias de la herida ocurren después del alta. Es la complicación postoperatoria más común y el motivo más frecuente de reingreso después del procedimiento quirúrgico. Poco se sabe sobre los costos a largo plazo de las complicaciones de la herida después del alta quirúrgica.OBJETIVO:Intentar en comprender las diferencias en los costos y las características de las complicaciones de la herida, identificadas después del alta hospitalaria, en pacientes sometidos a cirugía colorrectal, en comparación con las complicaciones intrahospitalarias.DISEÑO:Estudio de cohorte observacional utilizando datos del Programa de Mejora de la Calidad Quirúrgica de la Administración de Salud de Veteranos.ENTORNO CLÍNICO:Administración de Veteranos.PACIENTES:Pacientes sometidos a resección colorrectal entre el 1/10/2007 y el 30/9/2014.PRINCIPALES MEDIDAS DE VALORACIÓN:Costos de atención ajustados al alta, 30 días y 90 días después de la cirugía.RESULTADOS:De 20146 procedimientos, el 11,9% tuvo una complicación de la herida dentro de los 30 días de la cirugía. (49,2% índice hospitalario, 50,8% después del alta). En comparación con los pacientes, del índice de complicaciones hospitalarias, los pacientes con complicaciones posteriores al alta, tuvieron menos infecciones superficiales (65,0% frente a 72,2%, p <0,01), más infecciones de órganos/espacios quirúrgicos (14,3% frente a 10,1%, p <0,01), tasas más altas de diabetes (29,1% versus 25,0%, p = 0,02), y deberían de haber tenido un abordaje laparoscópico para su cirugía (24,7% versus 18,2%, p <0,01). El costo promedio, incluida la cirugía a los 30 días, fue de $ 37,315 (desviación estándar = $ 29,319). En comparación con el índice de complicaciones de las herida hospitalaria, las complicaciones de la herida después del alta fueron $ 9,500 (22%, p <0,001) menor costo a los 30 días y $ 9,736 (15%, p<0,001) y menor costo a los 90 días. Los pacientes con índice de complicación de la herida hospitalaria, tenían un 40% menos de probabilidades de requerir reingreso a los 30 días, pero sus reingresos eran $ 12,518 más costosos que los reingresos entre los pacientes presentando complicación de la herida recién identificada después del alta (p <0,001).LIMITACIONES:Limitado a las características del paciente y los costos acumulados solo dentro del sistema VA.CONCLUSIONES:Pacientes con complicaciones de la herida post alta, tienen menores costos postoperatorios a los 30 y 90 días, que aquellos con complicaciones de la herida identificadas durante su índice de hospitalización y aproximadamente la mitad fueron tratados de forma ambulatoria.

Fragmentation of care in the blunt abdominal trauma patient: Capturing our true outcomes and impact on care.

BACKGROUND: Trauma care is associated with unplanned readmissions, which may occur at facilities other than the index treatment facility. This "fragmentation of care" may be associated with adverse outcomes. We evaluated a statewide database that includes readmissions to analyze the incidence and impact of FC. METHODS: The California Office of Statewide Health Planning and Development patient discharge data set was evaluated for calendar years 2016 to 2018. Patients 15 years or older diagnosed with blunt abdominal solid organ injury during the index admission were identified. Readmissions were evaluated postdischarge at 1, 3, and 6 months. Patients readmitted within 6 months to a facility other than the index admission facility (fragmented care [FC]) were compared with those readmitted to their index admission facility (non-FC). Logistic regression modeling was used to evaluate risk of FC. RESULTS: Of the total 1,580 patients, there were 752 FC (47.6%) and 828 (52.4%) non-FC. Readmissions representing FC at months 1, 3, and 6 were 40.3%, 49.3%, and 53.4%, respectively. At index admission, the groups were demographically and clinically similar, with similar rates of abdominal operations and complications. Non-FC patients had a higher rate of abdominal reoperation at readmission (5.8% non-FC vs. 2.9% FC, p = 0.006). In an adjusted model, multiple readmissions (odds ratio [OR] 1.11, p = 0.014), readmission >30 days after index facility discharge (OR, 1.98; p < 0.001), and discharge to a nonmedical facility (OR, 2.46; p < 0.0001) were associated with increased odds of FC. Operative intervention at index admission was associated with lower odds of FC (OR, 0.77; p = 0.039). However, FC was not independently associated with demographic or insurance characteristics. CONCLUSION: The rate of FC among patients with blunt abdominal injury is high. The risk of FC is mitigated when patients are managed operatively during the index admission. Trauma systems should implement measures to ensure that these patients are followed postdischarge. LEVEL OF EVIDENCE: Prognostic and epidemiological, level III; Care management, level IV.

Acute urinary retention and risk of cancer: population based Danish cohort study.

OBJECTIVE: To examine the risk of urogenital, colorectal, and neurological cancers after a first diagnosis of acute urinary retention. DESIGN: Nationwide population based cohort study. SETTING: All hospitals in Denmark. PARTICIPANTS: 75 983 patients aged 50 years or older with a first hospital admission for acute urinary retention during 1995-2017. MAIN OUTCOME MEASURES: Absolute risk of urogenital, colorectal, and neurological cancer and excess risk of these cancers among patients with acute urinary retention compared with the general population. RESULTS: The absolute risk of prostate cancer after a first diagnosis of acute urinary retention was 5.1% (n=3198) at three months, 6.7% (n=4233) at one year, and 8.5% (n=5217) at five years. Within three months of follow-up, 218 excess cases of prostate cancer per 1000 person years were detected. An additional 21 excess cases per 1000 person years were detected during three to less than 12 months of follow-up, but beyond 12 months the excess risk was negligible. Within three months of follow-up the excess risk for urinary tract cancer was 56 per 1000 person years, for genital cancer in women was 24 per 1000 person years, for colorectal cancer was 12 per 1000 person years, and for neurological cancer was 2 per 1000 person years. For most of the studied cancers, the excess risk was confined to within three months of follow-up, but the risk of prostate and urinary tract cancer remained increased during three to less than 12 months of follow-up. In women, an excess risk of invasive bladder cancer persisted for several years. CONCLUSIONS: Acute urinary retention might be a clinical marker for occult urogenital, colorectal, and neurological cancers. Occult cancer should possibly be considered in patients aged 50 years or older presenting with acute urinary retention and no obvious underlying cause.

Continuity of care in acute survivorship phase, and short and long-term outcomes in prostate cancer patients.

Continuity of care is important for prostate cancer care due to multiple treatment options, and prolonged disease history. We examined the association between continuity of care and outcomes in Medicare beneficiaries with localized prostate cancer, and the moderating effect of race using Surveillance, Epidemiological, and End Results (SEER) - Medicare data between 2000 and 2016. Continuity of care was measured as visits dispersion (continuity of care index or COCI), and density (usual provider care index or UPCI) in acute survivorship phase. Outcomes were emergency room visits, hospitalizations, and cost during acute survivorship phase and mortality (all-cause and prostate cancer-specific) over follow-up phase. Higher continuity of care was associated with improved outcomes, and interaction between race and continuity of care was significant. Continuity of care during acute survivorship phase may lower the racial disparity in prostate cancer care. Future research can analyze the mechanism of the process.

Clinical impact of follow-up imaging on mortality in Korean breast cancer patients: A national cohort study.

BACKGROUND: As the incidence of breast cancer has increased and the survival rate has improved, supporting the optimal follow-up strategy has become an important issue. This study aimed to evaluate follow-up imaging usage after breast cancer surgery and the implications on mortality in Korea. METHODS: This study included 96,575 breast cancer patients diagnosed during 2002-2010 and registered in the Korea Central Cancer Registry, Statistics Korea, and Korean National Health Insurance Service. We evaluated the frequency of breast imaging (mammography and breast MRI) and systemic imaging for evaluating the presence of distant metastasis (chest CT, bone scan, and PET-CT), and performed analyses to determine if they had an effect on mortality. RESULTS: The median follow-up period was 72.9 months (range: 12.0-133.3) and 7.5% of the patients died. Among all patients, 54.7%, 16.2%, 45.6%, and 8.5% received 3 or more mammograms, chest CTs, bone scans, and PET-CTs within 3 years after surgery, respectively. Among patients who developed recurrence after 3 or more years, a comparison of overall mortality and breast-cancer specific mortality according to the frequency of imaging by modality (<3 vs. ≥3) showed that only mammography had significantly reduced mortality (hazard ratio [HR]: 0.72, 95% CI: 0.61-0.84, p < 0.0001; HR: 0.72, 95% CI: 0.61-0.84; p < 0.0001). CONCLUSIONS: This study showed that only frequent mammography reduced mortality and frequent imaging follow-up with other modalities did not when compared to less frequent imaging. This finding provides supportive evidence that clinicians need to adhere to the current guidelines for surveillance after breast cancer surgery.

Identifying metrics of success for transitional care practices in childhood cancer survivorship: A qualitative interview study of parents.

BACKGROUND: Survivor-focused care for adolescent and young adult (AYA) childhood cancer survivors (CCS) often involves their parents. Recognizing the importance of parents in the ongoing care of CCS, our study sought to identify key aspects of a successful transition for CCS from pediatric- to adult-centered care from the parent perspective. METHODS: We conducted qualitative interviews with 26 parents of CCS who were receiving care in the long-term follow-up (LTFU) clinic at a single institution. We used a semi-structured interview protocol with the parents and conducted a thematic content analysis. RESULTS: Using a constant comparison approach, data revealed three primary themes regarding parents' perspectives toward ensuring a seamless transition from pediatric- to adult-centered follow-up care: (1) the transition needs to include seamless communication between all involved parties, (2) survivors need to demonstrate sufficient health care self-efficacy in order to achieve a successful transition, and (3) the survivor-focused care should include support for survivors' overall well-being, including financial and health insurance literacy. CONCLUSIONS: For parents of AYA CCS, the optimal pediatric to adult care transition model should include mechanisms that facilitate communication between parents, CCS, and survivor-focused providers while also supporting self-efficacy and financial literacy as it relates to health insurance.

Pediatric surgical rib fixation: A collected case series of a rare entity.

BACKGROUND: Rib fractures are uncommon in children and are markers of extreme traumatic force from high-energy or nonaccidental etiology. Traditional care includes nonoperative management, with analgesia, ventilator support, and pulmonary physiotherapy. Surgical stabilization of rib fractures (SSRFs) has been associated with improved outcomes in adults. In children, SSRF is performed and its role remains unclear, with data only available from case reports. We created a collected case series of published pediatric SSRF cases, with the aim to provide a descriptive summary of the existing data. METHODS: Published cases of SSRF following thoracic trauma in patients younger than 18 years were identified. Collected data included demographics, injury mechanism, associated injuries, surgical indication(s), surgical technique, time to extubation, postoperative hospital stay, and postoperative follow-up. RESULTS: Six cases were identified. All were boys, with age range 6 to 16 years. Injury mechanism was high-energy blunt force in all cases, and all patients suffered multiple associated injuries. Five of six cases were related to motor vehicles, and one was horse-related. Indication(s) for surgery included ventilator dependence in five, significant chest deformity in two, and poor pain control in one case. Plating systems were used for rib stabilization in five of six cases, while intramedullary splint was used in one. All patients were extubated within 7 days following SSRF, and all were discharged by postoperative Day 20. On postoperative follow-up, no SSRF-related major issues were reported. One patient underwent hardware removal at 2 months. CONCLUSION: Surgical stabilization of rib fractures in children is safe and feasible, and should be considered as an alternative to nonoperative therapy in select pediatric thoracic trauma cases. Potential indications for SSRF in pediatric patients include poor pain control, chest wall deformity, or ventilator dependence. Further studies are needed to establish the role and possible benefits of SSRF in pediatric thoracic trauma. LEVEL OF EVIDENCE: Collected case series, level V.

Risk Factors for Loss to Follow-Up in the Lower Extremity Limb Salvage Population.

BACKGROUND: Limb salvage for chronic lower extremity wounds requires long-term care best delivered by specialized multidisciplinary centers. This optimizes function, reduces amputation rates, and improves mortality. These centers may be limited to urban/academic settings, making access and appropriate follow-up challenging. Therefore, the authors hypothesize that both system- and patient-related factors put this population at exceedingly high risk for loss to follow-up. METHODS: Records were reviewed retrospectively for 200 new patients seen at the Georgetown Center for Wound Healing in 2013. The primary outcome was loss to follow-up, defined as three consecutive missed appointments despite explicit documentation indicating the need for return visits. Demographic, clinical, and geographic data were compared. Multivariate logistic regression analysis for loss to follow-up status controlled for variables found significant in the bivariate analysis. Spatial dependency was evaluated using variograms. RESULTS: Over a 6.5-year-period, 49.5 percent of patients followed were lost to follow-up. Male sex and increased driving distance to the limb salvage center were risk factors for loss to follow-up. Wound-specific characteristics including ankle and knee/thigh location were also associated with higher rates of loss to follow-up. There was no spatial dependency or discrete clustering of at-risk patients. CONCLUSIONS: This study is the first of its kind to investigate the demographic and clinical characteristics that predispose chronic lower extremity wound patients to loss to follow-up. These findings inform stakeholders of the high rates of loss to follow-up and support decentralized specialty care, in the form of telemedicine, satellite facilities, and/or dedicated case managers. Future work will focus on targeting vulnerable populations through focused interventions to reduce patient and system burden. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Adherence to Follow-up Testing Recommendations in US Veterans Screened for Lung Cancer, 2015-2019.

Importance: Lung cancer screening (LCS) can reduce lung cancer mortality with close follow-up and adherence to management recommendations. Little is known about factors associated with adherence to LCS in real-world practice, with data limited to case series from selected LCS programs. Objective: To analyze adherence to follow-up based on standardized follow-up recommendations in a national cohort and to identify factors associated with delayed or absent follow-up. Design, Setting, and Participants: This retrospective cohort study was conducted in Veterans Health Administration (VHA) facilities across the US. Veterans were screened for lung cancer between 2015 to 2019 with sufficient follow-up time to receive recommended evaluation. Patient- and facility-level logistic regression analyses were performed. Data were analyzed from November 26, 2019, to December 16, 2020. Main Outcomes and Measures: Receipt of the recommended next step after initial LCS according to Lung CT Screening Reporting & Data System (Lung-RADS) category, as captured in VHA or Medicare claims. Results: Of 28 294 veterans (26 835 [94.8%] men; 21 969 individuals [77.6%] were White; mean [SD] age, 65.2 [5.5] years) who had an initial LCS examination, 17 863 veterans (63.1%) underwent recommended follow-up within the expected timeframe, whereas 3696 veterans (13.1%) underwent late evaluation, and 4439 veterans (15.7%) had no apparent evaluation. Facility-level differences were associated with 9.2% of the observed variation in rates of late or absent evaluation. In multivariable-adjusted models, Black veterans (odds ratio [OR], 1.19 [95% CI, 1.10-1.29]), veterans with posttraumatic stress disorder (OR, 1.13 [95% CI, 1.03-1.23]), veterans with substance use disorders (OR, 1.11 [95% CI, 1.01-1.22]), veterans with lower income (OR, 0.88 [95% CI, 0.79-0.98]), and those living at a greater distance from a VHA facility (OR, 1.06 [95% CI, 1.02-1.10]) were more likely to experience delayed or no follow-up; veterans with higher risk findings (Lung-RADS category 4 vs Lung-RADS category 1: OR, 0.35 [95% CI, 0.28-0.43]) and those screened in high LCS volume facilities (OR, 0.38 [95% CI, 0.21-0.67]) or academic facilities (OR, 0.86 [95% CI, 0.80-0.92]) were less likely to experience delayed or no follow-up. In sensitivity analyses, varying how stringently adherence was defined, expected evaluation ranged from 14 486 veterans (49.7%) under stringent definitions to 20 578 veterans (78.8%) under liberal definitions. Conclusions and Relevance: In this cohort study that captured follow-up care from the integrated VHA health care system and Medicare, less than two-thirds of patients received timely recommended follow-up after initial LCS, with higher risk of delayed or absent follow-up among marginalized populations, such as Black individuals, individuals with mental health disorders, and individuals with low income, that have long experienced disparities in lung cancer outcomes. Future work should focus on identifying facilities that promote high adherence and disseminating successful strategies to promote equity in LCS among marginalized populations.

The Colorectal Telephone Clinic: a new normal post-COVID-19?

INTRODUCTION: In light of the COVID-19 recommendations from the Association of Coloproctology of Great Britain and Ireland, we aimed to study patient and clinician satisfaction with a newly established telephone (TP) colorectal clinic service in lieu of traditional face-to-face (FTF) appointments. Comparative outcomes included patient versus clinician satisfaction; patient versus clinician desire to continue TP clinics postpandemic; and views of Specialty Trainee 3+ (ST3+)/Specialty Associate Specialist (SAS) doctors versus consultants on TP compared with FTF appointments. METHODS: We conducted a prospective service evaluation of patient and clinician satisfaction with colorectal surgery TP clinics between 1 June 2020 and 30 June 2020 in a British District General Hospital. RESULTS: Patients had higher satisfaction than clinicians with TP clinics: 91.5% versus 66.6% reported above-average experience [odds ratio (OR) = 5.35, 95% confidence interval (CI) 1.53 to 18.75, p = 0.01]. Clinicians had lower demand to continue TP clinics post-COVID-19 versus patients, with a trend towards significance (60% versus 82.9%, OR = 0.31, 95% CI 0.10 to 0.97, p = 0.08). ST3+/SAS doctors were more likely than consultants to find TP clinics inferior to FTF consultation for patient assessment (48.3% versus 23.7%, OR = 3.00, 95% CI 1.17 to 7.71, p = 0.03). CONCLUSIONS: While clinicians may be concerned that patient assessment suffers, patient satisfaction with TP clinics is high. There should be a place for TP clinics post-COVID-19 but there must be a robust process for patient selection as well as adequate training for current and future generations of clinicians.

Impact of the model of long-term follow-up care on adherence to guideline-recommended surveillance among survivors of adolescent and young adult cancers.

PURPOSE: Adolescent and young adult cancer survivors require lifelong healthcare to address the late effects of therapy. We examined the impact of different provider models of long-term follow-up (LTFU) care on adherence to recommended surveillance. METHODS: We conducted a retrospective cohort study using administrative health databases in Ontario, Canada. Five-year survivors were identified from IMPACT, a database of patients aged 15-20.9 years at diagnosis of six cancers between 1992 and 2010. We defined three models of LTFU care hierarchically: specialized survivor clinics (SCCs), general cancer clinics (GCCs), and family physician (FP). We assessed adherence to the Children's Oncology Group surveillance guidelines for cardiomyopathy and breast cancer. Multistate models assessed adherence transitions and impacts of LTFU attendance. RESULTS: A total of 1574 survivors were followed for a mean of 9.2 years (range 4.3-13.9 years) from index (5-year survival). The highest level of LTFU attended in the first 2-years post-index was a GCC (47%); only 16.7% attended a SCC. By the end of study, 72% no longer attended any of the models of care and only 2% still attended an SCC. Among 188 survivors requiring breast cancer surveillance, 6.9% were adherent to their first required surveillance testing. Attendance at a SCC in the previous year and higher cumulative FP or GCC visits increased the rate of subsequently becoming adherent. Among 857 survivors requiring cardiomyopathy surveillance, 11% were adherent at study entry. Each subsequent SCC visit led to an 11.3% (95% CI: 1.05-1.18) increase in the rate of becoming adherent. CONCLUSION: LTFU attendance and surveillance adherence are sub-optimal. SCC follow-up is associated with greater adherence, but few survivors receive such care, and this proportion diminished over time. Interventions are needed to improve LTFU attendance and promote surveillance adherence.

A population study of screening history and diagnostic outcomes of women with invasive cervical cancer.

BACKGROUND: Despite advances to prevent and detect cervical cancer, national targets for screening have not been met in the United States. Previous studies suggested that approximately half of women who developed cervical cancer were not adequately screened. This study aimed to provide an updated examination of women's screening and diagnostic practices five years prior to an invasive cervical cancer diagnosis. METHODS: The study included women age 21 years and older diagnosed with invasive cervical cancer in 2013-2016 from three population-based state cancer registries in the United States. Medical records abstraction identified screening history and diagnostic follow-up. A mailed survey provided sociodemographic data. Screening was a Pap or human papillomavirus (HPV) test between 6 months and 5 years before diagnosis. Adequate follow-up was defined per management guidelines. RESULTS: Of the 376 women, 60% (n = 228) had not been screened. Among women who received an abnormal screening result (n = 122), 67% (n = 82) had adequate follow-up. Predictors of: (a) being screened were younger age, having a higher income, and having insurance; (b) adequate follow-up were having a higher income, and (c) stage 1 cervical cancer were being screened and younger age. CONCLUSION: Unlike other cancer patterns of care studies, this study uses data obtained from medical records supplemented with self-report information to understand a woman's path to diagnosis, her follow-up care, and the stage of her cervical cancer diagnosis. This study provides findings that could be used to reach more unscreened or under screened women and to continue lowering cervical cancer incidence in the United States.

Results of paclitaxel-drug-coated balloons (Pantera Lux) for coronary in-stent restenosis: Italian experience from REGistry of Paclitaxel Eluting Balloon in ISR study.

AIMS: Drug-eluting stent (DES) implantation is an effective treatment of in-stent restenosis (ISR). However, literature data indicate that drug-coated balloons (DCBs) may be a valid alternative, particularly for recurrent ISR. We sought to evaluate clinical results on the long-term efficacy of a new DCB for ISR treatment. METHODS: One hundred and ninety-nine patients were treated with paclitaxel drug-coated balloons (Pantera Lux, Biotronik, Switzerland) in the Italian REGistry of Paclitaxel Eluting Balloon in ISR (REGPEB study). Clinical follow-up was scheduled at 1 and 12 months. A subgroup of patients received adjunctive 5-year follow-up. Primary end point was Major Adverse Cardiac Events (MACE) at 1 year. RESULTS: A total of 214 ISR coronary lesions were treated (75.4% DES-ISR). Mean time between stent implantation and DCB treatment is 41 months. DCBs were successfully delivered in 99% of the cases; crossover to a DES occurred in 3% of cases. Procedural success rate was 98.5%. Clinical success rate was 98.5%. First-month follow-up compliance was 98% and freedom from MACE was 96.9%. Twelve-month follow-up compliance was 89.3% with a freedom from MACE rate of 87.3% (CI: 81.3-91.5%). Five-year long-term follow-up showed 65.2% of freedom from MACE. CONCLUSION: Our study confirms that Pantera Lux treatment is effective and well tolerated in ISR, showing good acute and long/very long-term results in the treatment of complex lesions (DES and late ISR).